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Pediatrics International (2014) ••, ••–••
doi: 10.1111/ped.12497
Original Article
Neonatal clavicular fracture: Recent 10 year study Eun Sub Ahn,1 Moon Sun Jung,1 Yeon Kyung Lee,1 Sun Young Ko,1 Son Moon Shin1 and Myung Hoon Hahn2 Departments of 1Pediatrics, and 2Orthopedic Surgery, Cheil General Hospital and Women’s Health Care Center, Kwandong University College of Medicine, Seoul, Korea Abstract
Background: The clavicle is the bone most frequently fractured during the delivery process. Methods: A retrospective review was performed of all births with clavicular fractures from January 2003 to December 2012. Risk factors for fracture were determined and then compared to the control group. The data were compared and analyzed with previous studies. Results: Three hundred and nineteen cases of clavicular fracture (0.41% of total live births, n = 77 543) were identified. Prior to discharge, 275 cases (86.2%) were detected, and 44 cases (13.8%) were not detected until after discharge. Physical examination identified 144 cases (45.1%), while 175 cases (54.9%) were identified on chest X-ray incidentally. All babies with fracture, including five (1.6%) with brachial plexus palsy, recovered without treatment. Vacuum delivery was associated with a significantly higher incidence of clavicular fracture, as were mothers of advanced age with relatively shorter height. High birthweight, low head to chest circumference ratio and low Apgar score were other variables also significantly associated with clavicular fracture. On logistic regression analysis vacuum delivery and birthweight were significant risk factors. When analyzing and comparing findings from previous studies, only birthweight was identified as common to the risk factors affecting clavicular fracture. Conclusion: Major risk factors for clavicular fracture were vacuum delivery and birthweight. Considering the previous studies together, neonatal clavicular fracture appears to be a transient event without sequelae and most probably not preventable during birth.
Key words clavicular fracture, diagnosis, incidence, prognosis, risk factor.
Clavicular fracture is considered to be the most common birth injury, occurring at a rate of between 0.2 and 2.9% of all births.1–10 Clavicular fracture is a concern for parents and often a cause for discontent regarding the quality of delivery, but this fracture can be an unavoidable complication during birth. Although the exact mechanism of clavicular fracture during delivery is unclear, it is generally suggested that this fracture results from the compression of the fetal anterior shoulder against the maternal symphysis pubis.1 Diagnosis is made by clinical identification such as decreased Moro reflex, tenderness, swelling and crepitation of the affected shoulder, and radiography; its outcomes are typically benign.1,3,5,7 Previous studies have reported various risk factors for the occurrence of neonatal clavicular fracture during delivery, including birthweight, gestational age, Apgar score, prolonged labor, shoulder dystocia, instrumental vaginal delivery and maternal age, height and obesity.1–9 The aim of this study was therefore to determine the incidence, diagnosis and outcomes associated with clavicular fracture during the delivery process over a 10 year period, to Correspondence: Yeon Kyung Lee, MD, Departments of Pediatrics, Cheil General Hospital and Women’s Health Care Center, Kwandong University College of Medicine, 1-19, Mukjeongdong, Jung-gu, Seoul 100-380, Korea. Email: [email protected] Received 26 February 2014; revised 7 June 2014; accepted 13 June 2014.
© 2014 Japan Pediatric Society
analyze the risk factors for clavicular fracture, with respect to the control group, and to compare the data to previous studies.
Methods Study design
A retrospective analysis was done of the medical records of 319 infants with fractured clavicle among the 77 543 deliveries that occurred from January 2003 to December 2012 at Cheil General Hospital and Women’s Health Care Center, Kwandong University College of Medicine. Physical examination was performed both at the time of the infants’ admission to the nursery and before discharge. Clavicular fracture was confirmed on radiography. We investigated the time of detection, course of the fracture and neurological outcome before and after discharge. The control group consisted of vaginally delivered term babies whose birth immediately followed that of each the 289 babies with clavicular fracture (except for 14 born via cesarean section and 16 preterm babies in the 319 births). Maternal and intrapartum factors including age, parity, height, weight gain during pregnancy, gestational age and the use of epidural anesthesia, and fetal characteristics such as gender, birthweight, head to chest circumference ratio and Apgar score were considered and compared between the control and clavicular fracture groups. The data were then compared and analyzed with previous studies.
2
ES Ahn et al.
Table 1 Clinical features of clavicular fracture (n = 319) Sex Male Female Mode of delivery Vaginal Cesarean Gestational age Preterm Term Side of fracture Right Left Time of diagnosis Before discharge After discharge Cause of diagnosis Symptoms and exam Incidental on X-ray Brachial plexus palsy Prognosis (complete recovery)
n
%
171 148
53.6 46.4
305 14
95.6 4.4
16 303
5.0 95.0
222 97
69.6 30.4
275 44
86.2 13.8
144 175 5 319
45.1 54.9 1.6 100
Statistical analysis
Statistical analysis was performed using SPSS version 19.0 (SPSS, Chicago, IL, USA). Student’s t-test was used to compare continuous variables, and the chi-squared test was used for categorical variables. Multivariate logistic regression analysis was used to discriminate between two groups. P < 0.05 was considered to indicate statistical significance.
Results Clinical features
Of the 77 543 babies delivered, 319 cases of clavicular fracture were identified. The overall incidence was 0.41%. Of these, 0.65% of vaginal deliveries resulted in fracture, while only 0.05% of cesarean sections involved fracture. A total of 305 neonates with clavicular fracture were born via vaginal delivery, whereas 42 of them were delivered with the use of vacuum. The number of infants with a fracture who were born via cesarean section was 14, comprising 4.4% of the total number of fractures. Six cesarean sections were performed due to prior surgical history, such as previous cesarean section or uterine myoma; four were due to the mother having a small pelvis; two were due to failure to progress; and last, two were due to breech or transverse fetal presentation. Sixteen preterm babies with fracture were delivered between 32 and 36 weeks of gestation and were all born via vaginal delivery; two of these deliveries required vacuum assistance. The right clavicle was involved more often than the left clavicle, with right clavicular injury occurring in 222 neonates (69.6%) and left clavicular injury occurring in 97 neonates (30.4%; Table 1). Diagnosis of 150 (47.0%) of the fracture cases occurred on the day of birth, 72 cases (22.6%) were diagnosed on the second day, 27 cases (8.5%) on the third day and 70 cases on the fourth day or later (21.9%). A total of 275 cases (86.2%) were identified before discharge from hospital; 136 (42.6%) of these cases were © 2014 Japan Pediatric Society
diagnosed based on decreased Moro reflex, swelling, tenderness and crepitation of the affected site. Of the included cases, 30 (9.4%) were found due to suspicion of fracture during delivery, and 139 cases (43.6%) were detected by chance on chest X-ray conducted for the evaluation of respiratory symptoms. Forty-four cases (13.8%) were identified after discharge; of these cases, eight (2.5%) were identified on physical examination due to swelling and mass of clavicular area. The other 36 cases (11.3%) were found by chance on chest X-rays that were taken when the infant was admitted or visited an outpatient department. Five infants (1.6%) presented with symptoms of brachial plexus palsy such as weak and limited arm movement, but had benign outcomes without any sequelae (Table 1). Analysis of risk factors
After preterm babies and those delivered via cesarean section were excluded from analysis, a total of 289 babies with clavicular fracture were compared with the group of vaginally delivered term babies without fracture. Maternal factors such as parity, weight gain during pregnancy and the use of epidural anesthesia were not statistically significant. The mothers in the fracture group were significantly older, shorter, and were more likely to have undergone vacuum delivery (P < 0.05). In addition, the birthweight of the infants was significantly higher (P < 0.001) in the fracture group compared to the control group (3612 ± 410 g and 3298 ± 391 g, respectively). Fifty-two babies (18.0%) weighing ≥4000 g were found to have a fractured clavicle, whereas only 11 babies (3.8%) of that weight in the control group had a fracture (P < 0.001). Head to chest circumference ratio in the fracture group was 1.1 ± 0.9, which was significantly lower than that of the control group, which was 1.7 ± 2.5 (P = 0.018). Apgar scores at 1 and 5 min were significantly lower in the fracture group; Apgar score
Pediatrics International (2014) ••, ••–••
doi: 10.1111/ped.12497
Original Article
Neonatal clavicular fracture: Recent 10 year study Eun Sub Ahn,1 Moon Sun Jung,1 Yeon Kyung Lee,1 Sun Young Ko,1 Son Moon Shin1 and Myung Hoon Hahn2 Departments of 1Pediatrics, and 2Orthopedic Surgery, Cheil General Hospital and Women’s Health Care Center, Kwandong University College of Medicine, Seoul, Korea Abstract
Background: The clavicle is the bone most frequently fractured during the delivery process. Methods: A retrospective review was performed of all births with clavicular fractures from January 2003 to December 2012. Risk factors for fracture were determined and then compared to the control group. The data were compared and analyzed with previous studies. Results: Three hundred and nineteen cases of clavicular fracture (0.41% of total live births, n = 77 543) were identified. Prior to discharge, 275 cases (86.2%) were detected, and 44 cases (13.8%) were not detected until after discharge. Physical examination identified 144 cases (45.1%), while 175 cases (54.9%) were identified on chest X-ray incidentally. All babies with fracture, including five (1.6%) with brachial plexus palsy, recovered without treatment. Vacuum delivery was associated with a significantly higher incidence of clavicular fracture, as were mothers of advanced age with relatively shorter height. High birthweight, low head to chest circumference ratio and low Apgar score were other variables also significantly associated with clavicular fracture. On logistic regression analysis vacuum delivery and birthweight were significant risk factors. When analyzing and comparing findings from previous studies, only birthweight was identified as common to the risk factors affecting clavicular fracture. Conclusion: Major risk factors for clavicular fracture were vacuum delivery and birthweight. Considering the previous studies together, neonatal clavicular fracture appears to be a transient event without sequelae and most probably not preventable during birth.
Key words clavicular fracture, diagnosis, incidence, prognosis, risk factor.
Clavicular fracture is considered to be the most common birth injury, occurring at a rate of between 0.2 and 2.9% of all births.1–10 Clavicular fracture is a concern for parents and often a cause for discontent regarding the quality of delivery, but this fracture can be an unavoidable complication during birth. Although the exact mechanism of clavicular fracture during delivery is unclear, it is generally suggested that this fracture results from the compression of the fetal anterior shoulder against the maternal symphysis pubis.1 Diagnosis is made by clinical identification such as decreased Moro reflex, tenderness, swelling and crepitation of the affected shoulder, and radiography; its outcomes are typically benign.1,3,5,7 Previous studies have reported various risk factors for the occurrence of neonatal clavicular fracture during delivery, including birthweight, gestational age, Apgar score, prolonged labor, shoulder dystocia, instrumental vaginal delivery and maternal age, height and obesity.1–9 The aim of this study was therefore to determine the incidence, diagnosis and outcomes associated with clavicular fracture during the delivery process over a 10 year period, to Correspondence: Yeon Kyung Lee, MD, Departments of Pediatrics, Cheil General Hospital and Women’s Health Care Center, Kwandong University College of Medicine, 1-19, Mukjeongdong, Jung-gu, Seoul 100-380, Korea. Email: [email protected] Received 26 February 2014; revised 7 June 2014; accepted 13 June 2014.
© 2014 Japan Pediatric Society
analyze the risk factors for clavicular fracture, with respect to the control group, and to compare the data to previous studies.
Methods Study design
A retrospective analysis was done of the medical records of 319 infants with fractured clavicle among the 77 543 deliveries that occurred from January 2003 to December 2012 at Cheil General Hospital and Women’s Health Care Center, Kwandong University College of Medicine. Physical examination was performed both at the time of the infants’ admission to the nursery and before discharge. Clavicular fracture was confirmed on radiography. We investigated the time of detection, course of the fracture and neurological outcome before and after discharge. The control group consisted of vaginally delivered term babies whose birth immediately followed that of each the 289 babies with clavicular fracture (except for 14 born via cesarean section and 16 preterm babies in the 319 births). Maternal and intrapartum factors including age, parity, height, weight gain during pregnancy, gestational age and the use of epidural anesthesia, and fetal characteristics such as gender, birthweight, head to chest circumference ratio and Apgar score were considered and compared between the control and clavicular fracture groups. The data were then compared and analyzed with previous studies.
2
ES Ahn et al.
Table 1 Clinical features of clavicular fracture (n = 319) Sex Male Female Mode of delivery Vaginal Cesarean Gestational age Preterm Term Side of fracture Right Left Time of diagnosis Before discharge After discharge Cause of diagnosis Symptoms and exam Incidental on X-ray Brachial plexus palsy Prognosis (complete recovery)
n
%
171 148
53.6 46.4
305 14
95.6 4.4
16 303
5.0 95.0
222 97
69.6 30.4
275 44
86.2 13.8
144 175 5 319
45.1 54.9 1.6 100
Statistical analysis
Statistical analysis was performed using SPSS version 19.0 (SPSS, Chicago, IL, USA). Student’s t-test was used to compare continuous variables, and the chi-squared test was used for categorical variables. Multivariate logistic regression analysis was used to discriminate between two groups. P < 0.05 was considered to indicate statistical significance.
Results Clinical features
Of the 77 543 babies delivered, 319 cases of clavicular fracture were identified. The overall incidence was 0.41%. Of these, 0.65% of vaginal deliveries resulted in fracture, while only 0.05% of cesarean sections involved fracture. A total of 305 neonates with clavicular fracture were born via vaginal delivery, whereas 42 of them were delivered with the use of vacuum. The number of infants with a fracture who were born via cesarean section was 14, comprising 4.4% of the total number of fractures. Six cesarean sections were performed due to prior surgical history, such as previous cesarean section or uterine myoma; four were due to the mother having a small pelvis; two were due to failure to progress; and last, two were due to breech or transverse fetal presentation. Sixteen preterm babies with fracture were delivered between 32 and 36 weeks of gestation and were all born via vaginal delivery; two of these deliveries required vacuum assistance. The right clavicle was involved more often than the left clavicle, with right clavicular injury occurring in 222 neonates (69.6%) and left clavicular injury occurring in 97 neonates (30.4%; Table 1). Diagnosis of 150 (47.0%) of the fracture cases occurred on the day of birth, 72 cases (22.6%) were diagnosed on the second day, 27 cases (8.5%) on the third day and 70 cases on the fourth day or later (21.9%). A total of 275 cases (86.2%) were identified before discharge from hospital; 136 (42.6%) of these cases were © 2014 Japan Pediatric Society
diagnosed based on decreased Moro reflex, swelling, tenderness and crepitation of the affected site. Of the included cases, 30 (9.4%) were found due to suspicion of fracture during delivery, and 139 cases (43.6%) were detected by chance on chest X-ray conducted for the evaluation of respiratory symptoms. Forty-four cases (13.8%) were identified after discharge; of these cases, eight (2.5%) were identified on physical examination due to swelling and mass of clavicular area. The other 36 cases (11.3%) were found by chance on chest X-rays that were taken when the infant was admitted or visited an outpatient department. Five infants (1.6%) presented with symptoms of brachial plexus palsy such as weak and limited arm movement, but had benign outcomes without any sequelae (Table 1). Analysis of risk factors
After preterm babies and those delivered via cesarean section were excluded from analysis, a total of 289 babies with clavicular fracture were compared with the group of vaginally delivered term babies without fracture. Maternal factors such as parity, weight gain during pregnancy and the use of epidural anesthesia were not statistically significant. The mothers in the fracture group were significantly older, shorter, and were more likely to have undergone vacuum delivery (P < 0.05). In addition, the birthweight of the infants was significantly higher (P < 0.001) in the fracture group compared to the control group (3612 ± 410 g and 3298 ± 391 g, respectively). Fifty-two babies (18.0%) weighing ≥4000 g were found to have a fractured clavicle, whereas only 11 babies (3.8%) of that weight in the control group had a fracture (P < 0.001). Head to chest circumference ratio in the fracture group was 1.1 ± 0.9, which was significantly lower than that of the control group, which was 1.7 ± 2.5 (P = 0.018). Apgar scores at 1 and 5 min were significantly lower in the fracture group; Apgar score
